2017 Action of the Affordable Care Act

Published on: December 05, 2017

Affordable
Care Act Update

Congress spent much of 2017 focused on the repeal and replace of the Affordable Care Act (ACA). After many unsuccessful attempts to pass legislation in both the House and the Senate, the Trump Administration used executive authority to make significant changes to the law. In response, Senators Alexander and Murray introduced the Bipartisan Health Care Stabilization Act of 2017, with the intention of helping to stabilize the insurance marketplace. Below is a summary of Congress and the Administration’s actions on repeal and replace of the ACA that occurred in 2017

January

The fiscal year (FY) 2017 budget
resolution was introduced and approved, paving the way for consideration of
legislation focused on repealing the ACA. The resolution included specific
reconciliation instructions requiring the four committees of jurisdiction –
Ways and Means and Energy and Commerce in the House, and Finance and Health,
Education, Labor and Pensions (HELP) in the Senate – to draft reconciliation
legislation achieving at least $1 billion in deficit reduction over ten
years. Reconciliation legislation is
limited to amending provisions in law that would have a federal budget
consequence and only requires a majority of votes in the Senate (50 votes)
rather than the usual 60.

The U.S. House of Representatives released
legislation, the American Health Care Act (AHCA), to repeal and replace the
ACA. This legislation repealed the ACA's Medicaid expansion after 2020 and would
convert Medicaid to a per capita allotment or a block grant system. An
amendment to the legislation, introduced by Representatives Tom MacArthur
(R-NJ) and Mark Meadows (R-NC), allowed for states to apply for waivers to opt
out of certain ACA requirements, including the essential health benefits,
community rating, and age rating. ASH opposed this piece of legislation because
of concerns that it would reduce overall access to coverage and treatment and
would greatly impact patients with hematologic diseases and disorders.

ASH co-signed a letter with
several other medical specialty societies urging Congress to address
out-of-pocket costs in any new ACA legislation and a letter
expressing concerns about the changes to Medicaid under the AHCA.

May

On May 4th, the U.S. House of
Representatives voted on and passed the HR
1628,
the American Health Care Act, on a
party line vote of 217-213. The bill moved to the Senate for further consideration.

June

In late June, the Senate released its own
version of legislation to repeal and replace the ACA, the Better Care Reconciliation
Act (BCRA). While this legislation maintained the ACA requirement that insurers
accept everyone and charge the same rates, it did allow states to waive other
requirements, such as the rules for what benefits insurers must cover.
Beginning in 2020, Medicaid would be moved to a block grant or per capita
program, increasing the financial burden on states and most likely forcing many
states to cut back on coverage. Additionally, the legislation would allow
insurers to charge older consumers five times more than younger consumers, an
increase from three-to-one under the ACA. ASH opposed BCRA for the same reasons
the Society opposed the AHCA, because of concerns that this piece of
legislation would reduce overall access to coverage and treatment and would negatively
impact patients with hematologic diseases and disorders.

ASH, along with several other
public health organizations, signed a letter opposing the repeal of the Prevention and Public Health Fund
because of the impact this would have on discretionary health spending
including funding for the Centers for Disease Control and Prevention and other
federal public health agencies. Additionally, ASH wrote to all US Senators again outlining the Society’s priorities as
Congress moved forward with attempting to repeal and replace the ACA. Later in
the month, ASH again signed letters to defend
Medicaid funding and to oppose
the repeal of the Prevention and Public
Health Fund.

July

In late July, the U.S. Senate had its
chance to vote on and pass repeal legislation; however, the legislating body
could not garner enough support to pass any of the bills presented. These included a piece of legislation from 2015,
that would repeal but not replace the ACA; the Better Care Reconciliation Act,
a bill the Senate had been working on for two months; and finally, what was
being called the “skinny repeal,” bill which would have rolled back several key
provisions of the ACA. Three Republican
Senators, Susan Collins, Lisa Murkowski, and John McCain, joined Democrats to
vote against this final measure.

September

Senators Cassidy, Graham, Heller, and
Johnson introduced a new amendment to H.R. 1628, the American Health Care
Act. The legislation would have provided
block grants to states to cover the ACA’s premium subsidies, cost-sharing
reduction payments, and Medicaid expansion funding. The bill would also have allowed the states
to remove the essential health benefits (EHB) requirement, which would have
undermined the ACA’s patient protections, and would have moved Medicaid to a
per-capita allotment, making it more difficult for states to respond to
fluctuations in the price and demand for health care services. In order to pass legislation under the budget
reconciliation rules which only require a majority of votes in the Senate (50
votes), the legislation would have to be approved before October 1st;
however, due to a lack of support in the Senate, the amendment was never voted
on.

After Congress repeatedly failed to pass
legislation to repeal and replace the ACA, President Trump used the power of
the executive branch to make two significant changes to the law, both of which
could have a substantial impact on access to care.

The
first executive order seeks to increase competition by facilitating access to
association health plans (small businesses can join together to purchase
insurance coverage through associations), short-term limited duration insurance
products (plans that last less than a year), and health reimbursement
arrangements (employers can give employees money to purchase insurance rather
than provide it directly). Nothing is
changing immediately; rather, President Trump has directed several government
agencies to draft regulations to implement these new policies over the next 60
to 120 days. Experts disagree about whether and how these policies can be
implemented via regulation, so it is not clear what the effects will be. Since association health plans and short-term
insurance products do not need to follow a number of ACA patient protections
including the requirement for the essential health benefits, they could appeal
to younger, healthier people who seek less expensive, and therefore less
comprehensive coverage. This would raise
costs for people who need more complete coverage.

Secondly, after months of threatening to
do so, the Trump Administration announced its decision to end the cost-sharing
reduction (CSR) payments to insurers. The CSR payments were set up as subsidies
to insurance companies to help pay out-of-pocket costs for low-income
individuals, available to people with incomes of 100 percent to 250 percent of
the federal poverty level. Currently,
about seven million people benefit from the CSR payments but the change could
destabilize the marketplace and force insurers to drastically increase
premiums, impacting millions of others not currently benefiting from these
payments. In August, the Congressional Budget Office estimated that if the CSR
payments were stopped, premiums would increase by 20 percent in the following
year.

Senators Lamar Alexander and Patty Murray,
the ranking Republican and Democrat on the Senate Health, Education, Labor and
Pensions (HELP) Committee, respectively, introduced the Bipartisan Health Care
Stabilization Act, to help stabilize the insurance marketplace. The legislation
was introduced with the support of 12 Republicans and 12 Democrats, and would
restore the cost-sharing reduction (CSR) payments, recently cut off by the
Administration. The legislation would also expand access to catastrophic plans,
restore the funding for outreach and enrollment activities, and provide greater
flexibility to states when determining the affordability of health
insurance. ASH sent a letter
to all US Senators in early November expressing the Society’s support for this
legislation.